AIRWAYS MANAGEMENT

Respiratory Anatomy &

Physiology

Airway Anatomy
Upper Airway

Nose
Pharynx
Epiglottis
Glottis
Vocal cords
Larynx

Lower Airway

Trachea
Bronchi
Alveoli
Lung tissue,
consisting of lobes
and lobules (3 on
the right and 2 on
the left)
Pleura

Anatomy of Respiratory Tree

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Functions of the Upper

Airway

Passageway for air

Warm
Filter
Humidify
Protection
Gag Reflex
Cough

Speech

Physiology of Respiration
Define Respiration
The exchange of gases between a living
organism and the environment

Define Ventilation
Mechanical Process that moves air in
and out of the lungs

Basics of the Respiratory

System
Respiration

What is respiration?

Respiration = the series of exchanges that

leads to the uptake of oxygen by the cells, and
the release of carbon dioxide to the lungs
Step 1 = ventilation

Inspiration & expiration

Step 2 = exchange between alveoli (lungs) and

pulmonary
capillaries (blood)
Referred to as External Respiration

Step 3 = transport of gases in blood

Step 4 = exchange between blood and cells
Referred to as Internal Respiration

Cellular respiration = use of oxygen in ATP

synthesis

Schematic View of Respiration

External
Respiration

Internal
Respiration

Mechanics of breathing
Compliance:

This the ability of the lungs to stretch

during inspiration
lungs can stretch when under tension.
Elasticity:

It is the ability of the lungs to recoil to their

original collapsed shape during expiration
Elastin in the lungs helps recoil

Inspiration
Inspiration Active process
Diaphragm contracts -> increased
thoracic volume vertically.
Intercostals contract, expanding
rib cage -> increased thoracic
volume laterally.
More volume -> lowered pressure
-> air in.
Negative pressure breathing

Expiration
Expiration Passive
Due to recoil of elastic lungs.
Less volume -> pressure within alveoli is
just above atmospheric pressure -> air
leaves lungs.
Note: Residual volume of air is always
left behind, so alveoli do not collapse.

Lung Volumes
Tidal volume (TV): in/out with quiet breath
(500 ml)
Total minute volume: tidal x breaths/min

500 x 12 = 6 L/min

Lung Volumes
Inspiratory reserve volume (IRV): extra
(beyond TV) in with forced inspiration.
Expiratory reserve volume (ERV): extra
(beyond TV) out with forced expiration.
Residual volume: always left in lungs, even
with forced expiration.
Not measured with spirometer

Lung Capacities
Vital capacity (VC): the most you
can actually ever expire, with
forced inspiration and expiration.
VC= IRV + TV + ERV
Total lung capacity: VC plus
residual volume

Pulmonary Function

Insert fig. 16.16

Muscles of Breathing

Intercostal Muscles
Diaphragm

Regulation of Respiration
Where is the Respiratory Center Controlled?
Brainstem
Medulla
Apeustic Center (pons)
Pneumotaxic center (pons)

Stretch receptors
Hering-Breuer reflex

Chemoreceptors

Oxyhemoglobin Dissociation
Curve

Insert fig.16.34

AIRWAYS MANAGEMENT

ABC of Resuscitation
Airway: open the
airway
Breathing: provide
positive-pressure
ventilations
Circulation: give
chest compressions
Defibrillation: shock
VF/pulseless VT

Secondary Survey: ABCD

Airway :
provide advanced airway
management
Breathing : confirm tube placement
check for adequate oxygenation
and ventilation
Circulation : obtain IV access
determine rhythm
give medications
Differential Diagnosis : search for, find
and
treat reversible causes

Opening Airway
Head Tilt and Chin
Lift

Jaw Thrust

One hand applies downward

pressure to forehead and
index and middle finger of
the second hand lift at chin. For unstable cervical spine
Lifts tongue from posterior Place heels of hands on parieto-occipital area
Grasp angles of mandible with fingers, and
pharynx
displace jaw anteriorly.

PHARYNGEAL AIRWAY

Oropharyngeal Airway

Nasopharyngeal
Airway

1.Oropharyngeal Airway
Size is measured from the corner of
the mouth to the angle of the jaw
Sizes range from 0-6
It holds the tongue away from the
posterior pharynx, but does not
isolate the trachea

Technique
Clear the mouth
and pharynx
Place the airway so
that it is turned
backward as it
enters the mouth
As airway
approaches the
posterior wall of
the pharynx
rotate 180 degrees

2.Nasopharyngeal Airway
Soft plastic or rubber tube that is designed to
pass just inferior to the base of the tongue
Passed through one of the nares and can be
used in patients with an intact gag reflex
CONTRAINDICATED in cases of suspected or
possible basilar skull fracture
Sizes range from 17-26 cm in length and 6-9
mm internal diameter
Measured from tip of the nose to the corner of
the patients ear

Technique

lubrication

Complications
Airway trauma, particularly epistaxis
Incorrect size or placement will
compromise
effectiveness
Exacerbate injury in base of skull fracture,
with
NPA potentially displacing into the cranial
vault
Can still stimulate a gag reflex in sensitive
patients, precipitating vomiting or

Ventilate the Patient

1. Mouth to Mouth / Mouth to
Nose
2. Mouth-to-Mask
3. Bag-Mask

Types of Rescue Devices

LMA
Combitube
King

Laryngoscopes

Macintosh Blade

Miller Blade

Curved vs Straight Blade

Moderate head elevation (510 cm above the surgical table) and

extension of the atlantooccipital joint place the patient in the
desired sniffing position. The lower portion of the cervical spine
is flexed by resting the head on a pillow.

Combitube
E
Distal End
A
C

A = esophageal obturator; ventilation into trachea through

side openings = B
C = tracheal tube; ventilation through open end if proximal
end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at
level of teeth

Proximal End

H
D

Combi-tube
This is a multi-lumen airway that works
whether it is inserted into the esophagus or
the trachea
It either blocks the esophagus above and
below the glottic opening or by directly
ventilating the trachea
Contraindicated in patients under 5 foot tall
or those under 14 years old, in patients who
have ingested caustic substances, patients
with esophageal trauma or disease, and in
patients with an intact gag reflex

Combi-tube continued

Laryngeal Mask Airway

Sits over the glottic
opening
Available in different
sizes
Has a drain tube to
aid in gastric
suctioning
With some versions an
endotracheal tube
may be passed
through to aid in
intubation

LMA Positioning

Laryngeal Mask Airway

Laryngeal Mask Airway

Why

As an alternative to the face mask for achieving and

maintaining control of the airway.
LMA airways are indicated for use in:
Known or unexpected difficult airways
Establishing an airway during resuscitation in the
profoundly unconscious patient with absent gag reflex

Known Issues

Multiple sizes, based on weight, match correct syringe

with device to inflate cuff
Does not prevent aspiration
Improper placement (cuff folded over)
EDD is not recommended as a confirmation device with
the LMA
Is NOT a medication route for Endotracheal drugs

King Airway

King Airway
Why
Unconscious / unresponsive patients without gag reflex
Blind insertion technique
Alternative to E.T.T.

Known Issues
Obtaining proper seal / placement
Is NOT a medication route for Endotracheal drugs
Multiple sizes, based on height, also multiple cuff
volumes
Contraindications
Responsive patients with an intact gag reflex.
Patients with known esophageal disease.
Patients who have ingested caustic substances.